A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions?
Taking the infant's vital signs every 2 hr
Counting the number of wet diapers every shift
Weighing the infant at the same time every day
Measuring the infant's head circumference twice per day
The Correct Answer is C
A. Taking the infant's vital signs every 2 hr: Monitoring vital signs every 2 hours can help assess the infant’s general condition and detect changes in heart rate and blood pressure, which can indicate changes in hydration status. However, it might not be sufficient alone to monitor fluid status.
B. Counting the number of wet diapers every shift: Tracking the number of wet diapers is an effective way to monitor the infant's fluid output and hydration status. An increase in wet diapers typically indicates improved hydration. This is a practical and non-invasive method for assessing the effectiveness of IV therapy in infants.
C. Weighing the infant at the same time every day: Daily weights are a critical measure of fluid balance in infants. A consistent daily weight check provides a direct and accurate assessment of the infant’s hydration status and response to IV therapy.
D. Measuring the infant's head circumference twice per day: Measuring head circumference is not relevant for monitoring hydration status. It is typically used to assess growth and development in infants, not fluid balance or response to IV therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You should give your child's last daily dose of the medication before 6 o'clock in the evening." Methylphenidate is a stimulant, and giving it too late in the day can cause insomnia. Administering the last dose before 6 PM helps minimize sleep disturbances.
B. "You will need to give your child the medication after meals." Methylphenidate is typically given before meals to enhance its absorption and effectiveness. Taking it after meals is not recommended as it can delay absorption.
C. "You will need to have your child's blood glucose level checked monthly." There is no need for regular blood glucose monitoring unless the child has other conditions like diabetes. Methylphenidate does not typically affect blood glucose levels.
D. "You should not give your child the medication on weekends." Continuous use of methylphenidate is generally recommended to provide consistent symptom control, including on weekends. “Drug holidays” may be considered in specific cases but should be discussed with a healthcare provider.
Correct Answer is D
Explanation
A. Diarrhea: Not typically associated with Wilms' tumor, which affects the kidneys and presents primarily with abdominal symptoms.
B. Jaundice: Not a common symptom of Wilms' tumor, which involves the kidneys and usually does not affect liver function.
C. Swollen joints: This is more associated with conditions such as juvenile arthritis, not Wilms' tumor.
D. Abdominal mass: Wilms' tumor often presents as an asymptomatic abdominal mass that may be discovered during routine physical examination or parental bathing.
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